Intended for healthcare professionals

Analysis And Comment Health policy

Have targets improved performance in the English NHS?

BMJ 2006; 332 doi: (Published 16 February 2006) Cite this as: BMJ 2006;332:419
  1. Gwyn Bevan, professor of management science (,
  2. Christopher Hood, Gladstone professor of government2
  1. 1 Department of Operational Research, London School of Economics and Political Science, London WC2A 2AE
  2. 2 All Souls College, University of Oxford, Oxford OX1 4AL
  1. Correspondence to: G Bevan
  • Accepted 17 November 2005

The star rating system for NHS trusts seems to have improved performance, but we still don't know how genuine the improvements are or the costs to other services

Annual performance ratings have been published for NHS trusts in England since 2001, and the fifth and final set was published in July 2005.16 This process of naming and shaming gave each trust a rating from zero to three stars. Trusts that failed against a small number of key targets were at risk of being zero rated and their chief executives at risk of losing their job; trusts that performed well achieved three stars and were eligible for benefits from “earned autonomy.”7 Although the government has abandoned the star ratings, targets are likely to remain. We consider reported improvements in performance against key targets, problems of the system, and what ought to happen in the future.

Reported improvements in performance

We compared data on performance in England before and after the star rating system for three key targets. When data were available we also compared English data with that of other UK countries that did not adopt the star system.

Accident and emergency departments

The key target for accident and emergency departments was the percentage of patients to be seen within four hours. From March 2003, the target was 90%,3 5 and from January 2005 this increased to 98%.6 The National Audit Office reported that in England, in 2002, 23% of patients spent over four hours in accident and emergency, but in the three months from April to June 2004 only 5.3% stayed that longw1; this increased patient satisfaction and was achieved despite increasing use of emergency services.

Ambulance category A calls

England has had a target for category A calls (life threatening emergencies) since 1996, before star ratings were applied to ambulance trusts. The target …

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